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Your Guide to Prescription Drug Benefits2016 Preferred Formulary and Prescription Drug List
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Take Note
Use this page to list your medications and any questions to ask your doctor or pharmacist.
Prescription Drugs I Take Generic? Yes No__________________________________________________________
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Questions to ask:
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How to Contact Us
By TelephoneFor more information about your prescription drug benefit, call BlueCross BlueShield of Tennessee Member Service. The telephone number is 1-866-843-3509, Monday through Friday, 7 a.m. to 7 p.m. CT.
Online Visit the BlueCross website at www.bcbst.com/members/nissan to find out more about your prescription drug benefit. Log into BlueAccessSM to see the latest version of Your Guide to Prescription Drug Benefits.
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Important Information About Your Drug Plan
This guide lists brand-name and generic drugs most commonly prescribed for BlueCross BlueShield of Tennessee members; it is not a comprehensive listing of drugs. It encourages you and your doctor to select drugs recognized as the safest and most effective. Referring to this guide can help you understand how your drug plan works and save money on your prescriptions.
This guide may change at any time. If you are unable to find a particular drug in this guide, it does not necessarily mean that it is not covered. For a more complete listing of drug coverage and costs, you may use our Prescription Drug Search in BlueAccess at www.bcbst.com/members/nissan. You may also call Member Service at 1-866-843-3509 to confirm a drug’s tier status or verify prescription drug benefits.
A formulary is an expanded list of prescription drugs recommended by a health plan. BlueCross’ Pharmacy & Therapeutics (P&T) Committee consists of pharmacists and physicians, some of whom are community practitioners. On a quarterly basis, the P&T Committee reviews new drugs for possible placement on the formulary. The committee also routinely reviews all drugs for new safety and effectiveness information.
Check the Prescription Drug List
As a first step, check the Prescription Drug List on pages 6 - 11 to see if it includes drugs you currently take. You’ll see generic drugs are on the list, along with many popular brand drugs. If a drug you take is not on this list, talk with your doctor to see if one of the preferred drugs would be just as effective for you.
Working with your doctor and pharmacist, you can use the information in this brochure to make smart choices about the drugs you take and the amount you pay.
Please become familiar with these lists:
• Prescription Drug List (PDL) – A convenient list of the preferred and non-preferred brand drugs and generic medications that help save you money on your prescription costs. Depending on your drug plan and copay levels, your savings could be considerable.
• Specialty Drug List – These expensive injectable, infusion and oral medications are used to treat serious, chronic conditions such as multiple sclerosis, rheumatoid arthritis, cancer and hemophilia. They often require special handling, education and monitoring during treatment. It’s important to know some specialty drugs must be given in a doctor’s office (provider-administered), but others can be used at home (self-administered).
• Prior Authorization List (PA) – Specific drugs that may need authorization from your benefit plan before they are dispensed by your pharmacy.
• Step Therapy (ST) – Before using a brand-name drug, you may need to first try a similar, alternative medication.• Quantity Limitations List (QL) – In keeping with standard medical practices, certain drugs have limits on the
amount that can be purchased at one time.
• Formulary Exclusions List – Many plans do not reimburse for certain drugs. In some cases, there are alternative products available.
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It’s important to understand how your benefits work and be familiar with the drug choices that are appropriate for you. More information is provided on the BlueCross website at www.bcbst.com/members/nissan. Simply log into BlueAccess for tips that can help make the most of your prescription drug benefits:
1. Talk with your doctor. Doctors are your partners in achieving and maintaining your good health, so discuss every aspect of the prescribed treatment, including the selection of drugs. The more you know, the better your choices. Show your doctor the Prescription Drug List and discuss the options appropriate for you.
2. Ask for generic drugs. The U.S. Food and Drug Administration (FDA) requires generic drugs to have the same quality, strength and purity as brand-name drugs. You will pay less for generic drugs almost every time. Under your BlueCross plan, if you request a brand name drug that has a generic equivalent, you will incur a penalty. When a penalty is applied, it will require you to pay the Tier 1 amount plus the cost difference between the brand name drug and the generic equivalent.
3. Turn to your pharmacist. Your pharmacist can answer questions about the drugs you take, help you avoid harmful drug interactions, and help you select appropriate, lower-cost generics and preferred brands whenever available.
4. Use a network pharmacy. Network and Nissan Family Pharmacies fill your prescriptions and file the claims for you, making the process quicker and easier. Check www.bcbst.com/members/nissan for a list of network pharmacies.
5. Above all, be a smart consumer. The prescription drug industry spends more than $4 billion on advertising each year to promote its brands. Those costs are passed along to consumers, insurance companies and businesses. So choose a drug based on its effectiveness – not its advertising slogan.
Tips on Using Your Prescription Drug Benefits
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It’s Also Important to Remember:
1. Some medications are available through Mandatory Specialty Drug Vendors. (See page 13-15 for the list.) You will only receive benefits when you order specialty drugs through one of the mandatory specialty drug vendors. Your plan will allow you to receive a one-time 30-day specialty prescription at a retail pharmacy (first fill only).
2. Some medications require prior authorization or step therapy. (See page 16-17 for the list.) Network doctors are usually familiar with these lists and know how to get authorizations. However, you may want to show this list to your doctor.
3. Some medications have quantity limitations. Benefits for most covered prescriptions are provided for up to a month’s supply. But some drugs are limited to a specific amount or dose. (See page 18 for the list.)
4. Quantities of less than a month’s supply. Coverage for prescription drugs commercially packaged or commonly dispensed in quantities less than a one-month supply will be subject to coinsurance, as long as the quantity does not exceed the FDA-approved dosage for four calendar weeks.
5. Some types of medications are not covered by your plan. (See page 18 for exclusions list.) An exclusion does not mean you cannot have a particular drug. It simply means that no benefits will be provided, and you will be responsible for the total cost of the drug. Please contact Member Service if you are unsure if a drug is covered. The number is 1-866-843-3509.
6. You can visit our website. With the multi-level approach to prescription coinsurance from BlueCross, you play an important role in managing your benefits costs. Visit our website at www.bcbst.com/members/nissan for more information about how to get the most out of your drug benefits.
What You’ll Find on Our Website www.bcbst.com/members/nissan
Your prescription drug benefits from BlueCross include many useful tools to help you get the most from your pharmacy benefits. In addition to the information in this booklet, you can log into BlueAccess at www.bcbst.com/members/nissan to find these easy-to-use tools:
• Online prescription services — place mail order refill requests and track prescription orders
• Check drug cost — get the estimated cost of your medication and find out about possible generic alternatives, mail order options, and savings opportunities
• Consumer Reports – link to Consumer Reports Best Buy DrugsTM that includes cost, effectiveness and safety information
• Specialist Pharmacists – get an extra level of prescription drug support for members with ongoing conditions that use mail order
• Personal reminders — create and schedule refill reminders and order status alerts for mail order prescriptions
• Drug and health information — search the formulary to find out the tier status of your drug, check drug interaction and side effects, compare your drug to other drugs in the same therapy class, and get health and wellness information
• Pharmacy locator — find a participating pharmacy• Methods of payment — pay by credit card, check
or money order.
RememberYou or your physician may appeal the denial of a drug benefit or a drug quantity limit by faxing supportive documents and information to 1-888-343-4232. Please call Member Service at 1-866-843-3509 if you have questions about your grievance rights.
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Did you know some over-the-counter (OTC) medications are exactly the same as some prescription drugs – and usually cost significantly less? Whether you need relief from seasonal allergies, heartburn, certain skin problems, or other minor health concerns, you can often get the relief you need, without a prescription from your doctor.
You can learn more about OTC medications and which ones are available at their original prescription-strength without a prescription at www.bcbst.com/members/nissan.
It’s important to know your benefit plan may not cover prescription drugs that have OTC equivalents. There are more than 100,000 OTC products that contain ingredients previously available by prescription only, so talk with your doctor or pharmacist about which ones might work for you. Most plans do not cover OTC products, but since these usually cost less than prescription drugs, you could end up spending less on the medications you need.
Over-the-counter medications — Relief you need, when you need it
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2016 Prescription Drug List
Use Your Prescription Drug List to Save Time and MoneyPrescription drugs can be costly, but many are now available as generics. Generic drugs work the same as brand-name drugs, but cost less. Depending on your drug benefit, using generic drugs may lower your cost share. Generic Equivalents are made with the same active ingredients in the same dosage and form as a brand-name product, and provides the same therapeutic effects as the brand-name drug. Not all brand-name drugs have generic equivalents, but many do. Generic Alternatives may be used to treat the same condition as a brand-name drug. However, it may have a different chemical formula and ingredients. Talk to your doctor or pharmacist if you have questions about generic alternatives.
What’s a Drug Tier? The drug list includes three tiers of medications: generic, preferred brand-name drugs and non-preferred brand name drugs. Your copay or coinsurance for your prescription is based on which tier your drug falls into.
For more details, log into BlueAccess at www.bcbst.com/members/nissan.
Tier 1 — GenericTier 1 drugs are typically the most affordable and offer you the lowest available copayment or coinsurance. The active ingredient in a generic drug is chemically identical to the active ingredient of the corresponding brand-name drug. To help lower your out-of-pocket costs, we encourage you to choose a generic medication whenever possible. Look for these drugs under “Tier 1” in this guide.
Tier 2 — Preferred brandTier 2 drugs are usually available at a slightly higher copay or coinsurance than generic drugs. These drugs are designated preferred brand because they have been proven to be safe, effective, and favorably priced compared to other brand drugs that treat the same condition. Look for these drugs under “Tier 2” in this guide.
Tier 3 — Non-preferred brandTier 3 drugs usually have the highest copay or coinsurance and do not apply to your drug out-of-pocket maximum. These drugs are listed as non-preferred because they have not been found to be any more cost effective than available generics, preferred brands, or over-the-counter drugs. Look for these drugs under “Tier 3” in this guide.
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PA — This drug requires prior authorizationST — Requires other selected drugs to be tried firstQL — This drug has quantity limits on amount coveredSPRx — Specialty drug. Many plans require you to get this type of drug from a Specialty PharmacyThis list is not all-inclusive and does not guarantee coverage. Visit www.bcbst.com/members/nissan for updates to the drug list.
Prescription Drug List for 2016 (List is subject to change prior to Jan. 1, 2016)Nissan-specific benefits are noted under red sections.
Allergy/Cough & Cold Tier 1azelastinebenzonatatebrompheniramine/pseudoephedrinebudesonide
codeine/guaifenesincyproheptadinedesloratadineflunisolide
fluticasonehydroxyzinelevocetirizine QL
Tier 2AsteproDymista
EpiPenQLEpiPen Jr.QL
Veramyst
Tier 3Beconase AQ STGrastek PA
Nasonex ST Omnaris ST
Oralair PA SPRxRagwitek PA
Asthma/COPDTier 1albuterol nebulizer solnbudesonide nebulizer suspipratropium
levabuterol nebulizer solnmontelukasttheophylline
zafirlukast
Tier 2Adcirca PAAdvair DiskusAdvair HFA Anoro ElliptaAsmanexAsmanex HFABreo ElliptaBrovana
Combivent RespimatDalirespDuleraFlovent HFAForadilPerforomistProAir HFA
ProAir RespiclickQVARSerevent DiskusSpirivaSpiriva RespimatSymbicortTudorza Pressair
Tier 3Aerospan Arcapta NeohalerAtrovent HFA
Proventil HFA STPulmicort FlexhalerStriverdi Respimat
Ventolin HFA STXopenex HFA ST
Anti-Infectives Antibiotics/Antifungal/AntiviralTier 1amoxicillinamoxicillin/potassium clavulanateampicillinazithromycincefdinircefuroximecephalexinciprofloxacin tabsclarithromycinclarithromycin ext-relclindamycin
clindamycin creamdoxycyclineerythromycinfamciclovirfluconazoleketoconazolelevofloxacinlinezolid QLmetronidazoleminocycline immediate-releasemoxifloxacin
nitrofurantoin macrocrystalsnystatinpenicillin VKribavirin PA SPRxsulfamethoxazole/trimethoprimterconazoletetracyclinevalacyclovirvalganciclovirZovirax ointment
Tier 2Cleocin OvulesClindesseHarvoni PA SPRx
Pegasys PA SPRxSovaldi PA SPRx
Tobi Podhaler QL SPRxXifaxan 550mg Zovirax cream
Tier 3AveloxCresemba
Noxafil Nuvessa
Antivirals HIV/AIDSTier 1
didanosinelamivudine/zidovudinenevirapine
stavudinezidovudine
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PA — This drug requires prior authorizationST — Requires other selected drugs to be tried firstQL — This drug has quantity limits on amount coveredSPRx — Specialty drug. Many plans require you to get this type of drug from a Specialty PharmacyThis list is not all-inclusive and does not guarantee coverage. Visit www.bcbst.com/members/nissan for updates to the drug list.
Tier 3
Atripla SPRxComplera SPRxCrixivanEdurantEmtrivaEpzicomEvotaz SPRx
IsentressKaletraLexivaNorvirPrezcobix SPRxPrezistaRescriptor
ReyatazSelzentryStribild SPRxSustivaTivicay SPRxTrizivirTriumeq SPRx
TruvadaTybostViraceptViramune XRVireadVitekta SPRxZiagen
Antineoplastics and ImmunosuppressantsTier 1anastrozoleazathioprine bicalutamidecyclosporine
exemestane letrozolemercaptopurinemethotrexate
mycophenolate mofetilsirolimustacrolimustamoxifen
Tier 2Alkeran LeukeranTier 3Cyclophosphamide Purixan
Cardiovascular Drugs Coagulation TherapyTier 1aspirin/dipyridamoleclopidogrelenoxaparin QL
dipyridamolefondaparinux QL
Jantovenwarfarin
Tier 2Brilinta Effient
Eliquis Pradaxa
Xarelto
Tier 3Advate H SPRx Advate L SPRx Advate M SPRxAdvate SPRxAdvate UH SPRx Alphanate SD SPRx Alphanate SPRx
Bebulin SPRx BeneFIX SPRx Corifact SPRxFragmin QLHelixate FS SPRx Hemofil-P SPRx Humate-P SPRx
Koate-DVI SPRx Kogenate FS SPRx Monoclate-P SPRx Profilnine SPRx Recombinate SPRx Tretten SPRxWilate SPRx
Cardiovascular Drugs High Blood PressureTier 1amlodipineamlodipine/benazeprilamlodipine/valsartan amlodipine/vasartan/hctzatenololbenazeprilbenazepril/hctzbisoprolol bisoprolol/hctzbumetanidecandesartan/hctzcaptoprilcaptopril/hctzcarvedilolclonidinediltiazem ext-rel
enalaprilenalapril/hctzeplerenoneeprosartanfosinoprilfosinopril/hctzfurosemideguanfacinehydrochlorothiazideindapamideirbesartanirbesartan/hctzlisinoprillisinopril/hctzlosartan losartan/hctz
metoprololmetoprolol ext-relnifedipine ext-relpropranololquinaprilquinapril/hctzramiprilspironolactonetelmisartantelmisartan/amlodipinetelmisartan/hctztriamterene/hctzvalsartanvalsartan/hctzverapamil ext-rel
Tier 2AzorBenicarBenicar HCT
BystolicCoreg CR
Tribenzor
Tier 3AtacandDiovanDiovan HCTEdarbi ST
Edarbyclor STMicardis Micardis HCT
Teveten STTeveten HCT STTwynsta
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PA — This drug requires prior authorizationST — Requires other selected drugs to be tried firstQL — This drug has quantity limits on amount coveredSPRx — Specialty drug. Many plans require you to get this type of drug from a Specialty PharmacyThis list is not all-inclusive and does not guarantee coverage. Visit www.bcbst.com/members/nissan for updates to the drug list.
Cardiovascular Drugs High CholesterolTier 1atorvastatincholestyraminefenofibrate fenofibric acid
fluvastatin gemfibrozillovastatin
niacin ext-rel pravastatin simvastatin
Tier 2CrestorLiptruzet
Simcor Vytorin
Zetia
Tier 3AltoprevLescol XL
Livalo Niaspan
Welchol
Cardiovascular Drugs OtherTier 1amiodaronedigoxin
propafenonequinidine
sotalol
Tier 3Corlanor
Central Nervous System Anxiety/DepressionTier 1alprazolambupropionbupropion ext-relchlordiazepoxidecitalopramclorazepate
diazepamduloxetineescitalopramfluoxetinelorazepammirtazapine
paroxetine paroxetine ext-relsertralinevenlafaxinevenlafaxine ext-rel
Tier 2Pristiq ERTier 3Cymbalta
Central Nervous System Attention Deficit DisorderTier 1clonidine ext-reldextroamphetamine ext-rel
guanfacine ext-rel methylphenidate
methylphenidate ext-rel
Tier 2Adderall XRDaytrana
Quillivant XRStrattera
Vyvanse
Tier 3Focalin XR
Central Nervous System MigraineTier 1alomtriptan QLbutalbital combos
naratriptan QLrizatriptan QL
sumatriptan QLzolmitriptan QL
Tier 2Relpax QL
Tier 3Frova QL Sumavel Dosepro QL
Central Nervous System Seizure Disorders Tier 1carbamazepineclonazepamdivalproex divalproex ext-relfelbamategabapentin QL
gabapentin lamotriginelamotrigine QLlevetiracetamoxcarbazepinephenobarbital
phenytoin primidonetopiramate QLtopiramine QLvalproic acidzonisamide
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PA — This drug requires prior authorizationST — Requires other selected drugs to be tried firstQL — This drug has quantity limits on amount coveredSPRx — Specialty drug. Many plans require you to get this type of drug from a Specialty PharmacyThis list is not all-inclusive and does not guarantee coverage. Visit www.bcbst.com/members/nissan for updates to the drug list.
Tier 2DilantinOxtellar XR
Qudexy XRTrokendi XR
Vimpat
Tier 3AptiomFycompa
Onfi Potiga
Central Nervous System Sleep AgentsTier 1eszopiclonezaleplon
zolpidem zolpidem ext-rel
Tier 3Lunesta Rozerem
Central Nervous System OtherTier 1amantadinearipiprazole PAbenztropinecarbidopa/levodopacarbidopa/levodopa/entacaponeclozapine PAdonepezil
gabapentingalantamineGlatopa SPRxmemantinemodafinil PAolanzapine PAolanzapine/fluoxetine PA
pramipexolequetiapine PA risperidone PArivastigmine ropiniroleziprasidone PA
Tier 2Abilify PAAmpyra PA SPRxAvonex SPRxCopaxone SPRx
Exelon PatchGilenya PA SPRx Latuda PALyrica Namenda XR
Nuvigil PARebif SPRx SavellaSeroquel XR PATecfidera PA SPRx
Tier 3Aubagio PA SPRxBetaseron ST SPRx Extavia SPRxFanapt PA
Fazaclo PAGeodon PAInvega PANamzaric
NuedextaPlegridy SPRxSaphris PA
DermatologyTier 1adapaleneAmnesteembetamethasoneClaravisclindamycin/benzoyl peroxideclindamycin topicalclobetasolclotrimazole/betamethasonedesonide
desoximetasone econazoleerythromycin topicalfluocinonidefluticasonehydrocortisone 2.5%ketoconazolelindane
metronidazole topicalmometasonemupirocin nystatinnystatin/triamcinoloneRetin-A Micro PAsilver sulfadiazinetacrolimustriamcinolone
Tier 2AcanyaAtralin
ElidelEpiduo
Tier 3CaracDermasorb TADermasorb HC
DifferinFabior PAFinacea
PicatoTazorac PAZyclara
Diabetes Blood Glucose Monitoring (No copay for diabetic testing supplies)Tier 2Bayer Contour/Breeze2 products QL Lifescan OneTouch products QL
Tier 3Abbott Freestyle products QL ST Roche Accu-Chek products QL ST
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PA — This drug requires prior authorizationST — Requires other selected drugs to be tried firstQL — This drug has quantity limits on amount coveredSPRx — Specialty drug. Many plans require you to get this type of drug from a Specialty PharmacyThis list is not all-inclusive and does not guarantee coverage. Visit www.bcbst.com/members/nissan for updates to the drug list.
Diabetes Diabetic DrugsTier 1glimepirideglipizideglipizide ext-relglyburide
glyburide/metforminmetforminmetformin ext-relnateglinide
pioglitazonepioglitazone/glimepiridepioglitazone/metforminrepaglinide
Tier 2Bydureon ByettaFarxigaGlucagon emergency kitGlyxambi
InvokanaInvokametJanumet Janumet XRJanuvia
JentaduetoTradjentaV-GoVictozaXigduo XR
Diabetes InsulinTier 2BD syringesLantus pens and vials Levemir vials/pens
NovolinNovolog
Novolog MixToujeo SoloStar
Tier 3Apidra STAfrezza
Humalog STHumulin ST
Humulin Kwikpen ST
Eye/EarTier 1bimatoprost 0.03%brimonidine bromfenac carteolol solutionciprofloxacin oticdiclofenac sodium ophthalmic
gentamicin ophthalmicketotifenlatanoprostnaphazolineofloxacinolopatadine
polymyxin B/bacitracin/neomycin ophthalmicpolymyxin B/neomycin/hydrocortisone oticpolymyxin B/trimethoprim ophthalmictimolol maleatetobramycin ophthalmictravoprost
Tier 2AlrexAzoptBepreveBetimolLumigan
PatadayPatanolPazeoProlensaRestasis
Tobradex OintmentTobraDex STTravatan ZZylet
Tier 3CiprodexRescula ST
SimbrinzaVigamox
Xalatan STZioptan ST
Gastrointestinal Agents Tier 1cimetidinediphenoxylate/atropinefamotidine granisetron lactulose lansoprazole
lansoprazole QLNexiumnizatidineomeprazoleomeprazole QL metoclopramide
ondansetron pantoprazole promethazineranitidine sulfasalazine
Tier 2AmitizaAnalpram AdvancedAnalpram HCAprisoAsacol HD Canasa
CreonDelzicolKristaloseLialda LinzessPentasa
Prepopik SuclearSuprepUceris Zenpep
Tier 3Anzemet Emend Fulyzaq
Gout TherapyTier 1allopurinol probenecidTier 2Colcrys Uloric
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PA — This drug requires prior authorizationST — Requires other selected drugs to be tried firstQL — This drug has quantity limits on amount coveredSPRx — Specialty drug. Many plans require you to get this type of drug from a Specialty PharmacyThis list is not all-inclusive and does not guarantee coverage. Visit www.bcbst.com/members/nissan for updates to the drug list.
Hormone ReplacementTier 1estradiolestradiol transdermal
estropipatemedroxyprogesterone
progesterone
Tier 2Androgel PACenestin Divigel
EnjuviaEvamist Premarin
PremphasePrempro Vagifem
Tier 3Androderm PAClimara Pro
CombipatchDuavee
Testim PA ST
Miscellaneous OB/GYN Drugs Tier 2 Osphena
Oral Contraceptives MonophasicTier 1all generic monophasicApriAviane Gianvi
Junel Junel FeLevoraLow-Ogestrel
MicrogestinMicrogestin FeNecon 1/35, 1/50Ocella
Tier 2Minastrin 24 FE
Tier 3Beyaz
Oral Contraceptives BiphasicTier 1all generic biphasic KarivaOral Contraceptives TriphasicTier 1all generic triphasicEnpresseNecon 7/7/7norgestimate/ethinyl estradiol
Tilia FETri-Legest FETri-PrevifemTri-Sprintec
TrinessaTrivora
Tier 2Lo Loestrin FETier 3Ortho Tri-Cyclen Lo
Oral Contraceptives OtherTier 1all generic extended-cycleall generic progestinAmethia Lo
CamilaCamrese LoErrin
JolivetteXulane
Tier 2NuvaRingOsteoporosis/Bone DiseasesTier 1alendronatealendronate plus OTC Vitamin D
calcitonin-salmonibandronate
raloxifenerisedronate
Tier 2Actonel Atelvia
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PA — This drug requires prior authorizationST — Requires other selected drugs to be tried firstQL — This drug has quantity limits on amount coveredSPRx — Specialty drug. Many plans require you to get this type of drug from a Specialty PharmacyThis list is not all-inclusive and does not guarantee coverage. Visit www.bcbst.com/members/nissan for updates to the drug list.
RheumatologyTier 1celecoxibdiclofenac QLdiclofenac/misoprostoletodolacibuprofen
indomethacinketoprofen QLleflunomidemeloxicam QLmethotrexate
nabumetonenaproxennaproxen sodiumpiroxicamsulindac
Tier 3Actemra SQ PA ST SPRx Enbrel PA SPRx
Humira PA SPRxOrencia SubQ PA ST SPRxXeljanz PA ST SPRx
Thyroid MedicationsTier 1levothyroxine Tier 3Armour Thyroid SynthroidUrologic DisordersTier 1alfuzosin doxazosinfinasteride oxybutynin
oxybutynin ext-relprazosin tamsulosin
terazosintolterodinetrospium
Tier 2EnablexGelnique
MyrbetriqVesicare
Tier 3AvodartDetrol LA
JalynRapaflo
Vitamins (prescription only)Tier 1all generics
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Specialty Pharmacy Network
Specialty drugs are expensive injectable, infusion and oral medications used to treat serious, chronic conditions such as multiple sclerosis, rheumatoid arthritis, cancer and hemophilia. And they often require special handling, education and monitoring during treatment. It’s important to know some specialty drugs must be given in a doctor’s office (provider-administered), but others can be used at home (self-administered).
The Specialty Pharmacy Network includes experts in these high-cost, biologic drugs and to offer these medications at special rates. When your doctor writes your prescription and faxes it to the specialty pharmacy your medicine will be sent to your home or other designated location. Plus, pharmacists and nurse specialists are available to answer any questions or concerns about your medication.
Depending on your specific plan coverage, your copay may be higher or the medication may not be covered if you purchase self-administered specialty drugs from another pharmacy instead of a pharmacy in the BlueCross BlueShield of Tennessee Specialty Pharmacy Network.
The physician may obtain approval and order Specialty Pharmacy Products by calling one of these Specialty Pharmacies. You may also order self-administered drugs from one of these Specialty Pharmacies:
Nissan Family Pharmacy Smyrna 1-866-601-9156 fax 1-615-355-7639
Canton 1-800-237-2590 fax 1-601-407-1550
AcariaHealth, Inc. 1-855-405-6923 fax 1-866-892-3223
Accredo Health Group 1-888-239-0725 fax 1-866-387-1003
Acro Pharmaceutical Services 1-800-906-7798 fax 1-844-612-9057
Amerita, Inc. 1-855-778-2229 fax 1-877-801-1540
Axium Specialty Pharmacy 1-888-315-3395 fax 1-888-315-3270
BioPlus Specialty Pharmacy 1-888-292-0744 fax 1-800-269-5493
BriovaRx 1-866-791-8679 fax 1-888-791-7666
Caremark Specialty Pharmacy Services 1-800-237-2767 fax 1-800-323-2445
Entrust Specialty Pharmacy 1-855-273-3924 fax 1-855-273-3925
HPC Specialty Pharmacy 1-800-757-9192 fax 1-855-813-0583
NPS Pharmacy 1-866-406-9266 fax 1-866-420-4686
Restore Rx, Inc. 1-877-388-0507 fax 1-901-388-0407
Transcript Pharmacy, Inc. 1-866-420-4041 fax 1-844-407-4040
*Requests for participation in the BlueCross BlueShield of Tennessee Specialty Pharmacy Network are accepted in the months of June and July.
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Provider-Administered Medications Available Through the Specialty Pharmacy Network
Provider-administered specialty pharmacy products are ordered by a doctor and administered in an office or outpatient setting. To get Prior Authorization for provider-administered specialty drugs (shown below), your network doctor must do one of the following:
• Call BlueCross BlueShield of Tennessee at 1-800-924-7141
• Log on to BlueAccess, the secure area of bcbst.com, select Service Center from the Main menu, followed by Authorization/Advance Determination Submission. If your doctor is not registered with BlueAccess or needs help using bcbst.com, he or she can call eBusiness Solutions at 1-800-924-7141 (option 4) or 423-535-5717 (option 2).
Abilify Maintena
Abraxane
Actemra PA
Acthar H.P. Gel PA
Adagen
Adcetris PA
Aldurazyme MPC
Alferon N
Alimta PA
Amevive
Aralast NP
Aranesp PA
Arranon
Arzerra PA
Avastin PA
Beleodaq PA
Benlysta PA
Berinert PA
Blincyto PA
Botox MPC
Campath MPC
Camptosar
Cerezyme MPC
Cimzia vials PA
Cinryze PA
Cyramza PA
Cytovene IV
Dacogen
Dysport MPC
Elaprase
Elelyso PA
Eligard IMMPC
Eloxatin
Entyvio PA
Epogen PA
epoprostenol PA (Flolan, Veletri)
Erbitux PA
Erwinaze PA
Euflexxa MPC
Eylea
Fabrazyme
Firmagon
Folotyn PA
Gazyva PA
Gel One MPC
Gemzar
Granix PA
Halaven PA
Herceptin
Hyalgan MPC
Hycamtin inj
Hylenex
Ilaris MPC
Immune Globulins MPC
Intron A IV
Istodax PA
Ixempra
Jetrea PA
Jevtana
Kadcyla PA
Krystexxa PA
Kyprolis PA
Lemtrada PA
Leukine
Lucentis
Lumizyme MPC
Lupron Depot MPC
Macugen
Makena
Marqibo PA
mitoxantrone (Novantrone)
Mozobil
Myobloc MPC
Myozyme MPC
Naglazyme MPC
Neulasta
Neumega
Neupogen
NovoSeven RT
Nplate
Opdivo PA
Orencia PA
Orthovisc MPC
Ozurdex
Perjeta PA
Prialt
Procrit PA
Proleukin
Prolia PA
Provenge PA**
Qutenza
Remicade PA
Remodulin PA
Retisert
RiaSTAP
Risperdal Consta
Rituxan PA
Ruconest PA
Sandostatin LAR
Signifor LAR
Simponi Aria PA
Soliris PA
Somatuline
Stelara PA
Supartz MPC
Supprelin
Sylvant PA
Synagis PA
Synribo PA
Synvisc MPC
Synvisc One MPC
Temodar inj PA
Thyrogen
Torisel
Treanda PA
Trelstar
Trisenox
Tysabri PA
Unituxim PA
Vantas
Vectibix PA
Velcade PA
Vidaza MPC
Vimizim PA
Vistide
Visudyne
Vivitrol
Vpriv MPC
Xeomin MPC
Xgeva PA
Xiaflex MPC
Xolair PA
Yervoy PA
Zaltrap PA
Zemaira
Zoladex
zoledronic acid (Reclast, Zometa) MPC
PA This drug requires prior authorization before dispensing/administration.MPC Medical policy criteria must be satisfied. The criteria can be found at http://crossroads/med_policies/!SSL!/WebHelp/mpm2.htm** Provenge is not available through Bluecross’ Preferred SP Rx Pharmacies. Information on obtaining Provenge may be found at http://www.provenge.com/contact-us.aspx
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Self-Administered Medications Available Through the Specialty Pharmacy Network
This is a specialty drug you give yourself, usually by injection. To obtain Prior Authorization for self-administered specialty drugs (as noted below), your network physician must call Express Scripts at 1-877-916-2271.
Actemra SQ PA ST
Acthar H.P. Gel PA
Actimmune PA
Adcirca PA
Adempas PA
Advate
Advate H
Advate L
Advate M
Advate UH
Afinitor PA
Alphanate
Alphanate SD
Ampyra PA
Apokyn
Aranesp PA
Arcalyst
Astagraf XL
Atripla
Aubagio PA
Avonex
Bebulin
BeneFIX
Berinert PA
Betaseron PA*
bexarotene (Targretin) PA
Bosulif PA
capecitabine (Xeloda)
Caprelsa PA
Cayston PA
Cerdelga PA
Cholbam PA
Cimzia syringes PA ST
Cinryze PA
Cometriq
Complera
Copaxone
Corifact
Cystadane
Cystaran
Duopa PA
Enbrel PA
Epogen PA
epoprostenol PA (Flolan, Veletri)
Erivedge PA
Esbriet PA
Evotaz
Exjade
Extavia
Factors
Farydak PA
Ferriprox
Firazyr PA
Forteo
Fuzeon
Fuzeon
Gammagard Liquid PA
Gamunex C PA
Gattex PA
Gilenya PA
Gilotrif PA
Glatopa
Gleevec
Growth Hormone (Norditropin) PA
Harvoni PA
Helixate FS
Hemofil-P
Hizentra PA
Humate-P
Humira PA
Hycamtin oral
Hyquvia PA
Ibrance PA
Iclusig PA
Imbruvica PA
Incivek PA
Increlex PA
Infergen PA
Inlyta PA
Intron A SQPA
Jadenu
Jakafi PA
Juxtapid PA
Kalydeco PA
Kineret PA ST
Koate-DVI
Kogenate FS
KorlymPA
Kuvan
Kynamro PA
Lenvima PA
Letairis PA
leuprolide SQ (Lupron SQ)
Lyparza PA
Mekinist PA
Monoclate-P
Mozobil
Myalept PA
Natpara PA
Neulasta
Neumega
Neupogen
Nexavar PA
Northera PA
NovoSeven RT
octreotide SQ
(Sandostatin SQ)
Ofev PA
Opsumit PA
Oralair PA
Orencia SubQ PA ST
Orenitram PA
Orfadin
Orkambi PA
Otezla PA ST
Peg-Intron PA
Pegasys PA
Pegasys PA
Plegridy
Pomalyst PA
Prezcobix
Procrit PA.
Procysbi PA
Profilnine
Promacta
Pulmozyme
Ravicti
Rebif
Recombinate
Remodulin PA
Revlimid PA
ribavirin (Copegus, Rebetol,Ribasphere) PA
Sabril
Samsca
Sensipar
Signifor PA
sildenafil (Revatio) PA
Simponi PA ST
Somavert
Sovaldi PA
Sprycel
Stimate
Stivarga PA
Stribild
Sutent PA
Sylatron PA
Tafinlar PA
Tarceva PA
Tasigna
Tecfidera PA
temozolomide (Temodar oral) PA
Thalomid PA
Tivicay
Tobi QL
Tracleer PA
Tretten
Triumeq
Tykerb PA
Tyvaso PA
Valchlor PA
Ventavis PA
Victrelis PA
Vitekta
Votrient PA
Wilate
Xalkori PA
Xeljanz PA
Xenazine PA
Xtandi PA
Zavesca PA
Zelboraf PA
Zolinza
Zydelig PA
Zykadia PA
Zytiga
PA This drug requires prior authorization before dispensing/administration.PA* This product requires step therapy or prior authorizationThe following drugs may not be covered by your plan. Check with customer service to determine coverage. If covered by the plan, these drugs require prior authorization.+ anti-obesity drugs (e.g. benzphetamine, diethlpropion, orlistat (Xenical), phendimetrazine, phentermine, Belviq, Qsymia+ chemical dependency/detoxification (e.g. buprenorphine, buprenorphine/naloxone, Campral, disulfiram, Revia, Suboxone)+ erectile dysfunction drugs (e.g.) Caverject, Cialis, Edex, Levitra, Muse, Staxyn, Viagra)+ growth hormone (Norditropin)
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2016 Prior Authorization List
To maximize your benefits, the drugs listed below need authorization from your benefit plan before they are dispensed by your pharmacy. Your network physician is responsible for obtaining prior authorization when prescribing a drug on this list. Ask your physician to make the call at the same time the medication is prescribed so there will be no delay when you go to the pharmacy.
The following list of drugs requires prior authorization:
Drug Requirementallergy (e.g. Grastek, Ragwitek) PA requiredanabolic steroids (e.g., Anadrol-50, Oxandrin) PA requiredandrogens (e.g., Androderm, Androgel, Testim) PA required for males 30 years and younger; PA required for all femalesatypical antipsychotics (e.g., Abilify, Risperdal,
Seroquel, Zyprexa) PA required for patients 17 years and younger
modafinil PA requiredNuvigil PA requiredretinoids (e.g., Avita, Retin-A, Tazorac) PA required for patients 40 years and olderSpecialty Pharmacy Products Many of these drugs also require prior authorization. See Specialty Pharmacy Drug List.
Xyrem PA required
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2016 Step Therapy List
A form of prior authorization that begins drug therapy for a medical condition with the most cost-effective and safest drug therapy. To have these medications covered under your prescription drug benefit, you may be required to first try an alternative or complete the prior authorization process. It progresses to alternate drugs only if necessary. Prescription drugs subject to step therapy guidelines are: (1) used only for patients with certain conditions; (2) Covered only for patients who failed to respond to or demonstrated an intolerance to alternate prescription drugs as supported by appropriate medical documentation; and (3) when used with selected prescription drugs to treat your condition.
The following list of drugs requires step therapy:
Drug Requirement
Angiotensin II Receptor Blocker
Edarbi/Edarbyclor
Teveten/Teveten HCT
trial and failure of generic ARB or Benicar/Benicar HCT
Betaseron trial and failure of Avonex, Copaxone, Extavia, or Rebif
Diabetic Test Strips (Freestyle/Accu-Chek) trial and failure of preferred products made by Lifescan (OneTouch) or Bayer (Contour or Breeze2)
Glaucoma Agents
Rescula
Xalatan
Zioptan
trial and failure of latanoprost or Lumigan or Travatan Z
Humulin trial and failure of Novolin
Humalog / Apidra trial and failure of Novolog
Short-acting Beta Agonists
Proventil HFA
Ventolin HFA
Xopenex HFA
trial and failure of ProAir HFA and ProAir Respiclick
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2016 Quantity Limit List
Quantity limits help promote appropriate use of selected drugs and enhance patient safety. If your prescription is written for more than the allowed quantity, it will be filled to the allowed quantity. Your doctor can request a greater quantity for medical necessity reasons.
The following list of drugs require quantity limits:
Drug LimitAnaphylaxis Agents (e.g., Epipen, Epipen Jr.) 2 kits/30 daysDiabetic supplies 306 qty/30 days; 918 qty/90 daysLow molecular weight heparins (e.g., enoxaparin, fondaparinux, Arixtra, Fragmin,
Lovenox) 42 day supply/365 daysMigraine drug, injections and nasal spray:
Migranalsumatriptan (Imitrex, Alsuma) Injectionsumatriptan (Imitrex) nasal spraySumavel DoseproZomig nasal spray
Up to 1 kit in a 30-day periodUp to 8 syringes or vials/4 kits in a 30-day periodUp to 12 devices in a 30-day periodUp to 8 syringes or vials/4 kits in a 30-day periodUp to 2 cartons (40mg) in a 30-day period
Migraine drugs, tablets: 18 tablets in a 30-day periodalmotriptannaratriptan (Amerge)Relpaxrizatriptansumatriptan (Imitrex)zolmitriptan
Relenza One treatment course per 180-day periodSpecialty Pharmacy Products Limited to one month’s supplyTamiflu One treatment course per 180-day periodTobi Podhaler 224 Capsules/ 28 daysTobi, tobramycin ampules 56 ampules/ 28 dayslinezolid (Zyvox) 14 days of therapy, then PA requiredSmoking Cessation Drugs (OTC and Prescription) Limit is one treatment cycle every six months (30 day supply limit per monthly fill)Ella one tablet/Rx; 3 tablets/365 daysPain Medications:
apap/caffeine/dihydrocodeine (Trezix) 360 tablets/ 30 days buprenorphine/naloxone (Suboxone, Zubsolv) 90 tablets/ 30 daysbutalbital combinations 180 units/30 dayscodeine 180 units/30 dayscodeine/APAP 180 units/30 daysfentanyl lozenges & tablets (Abstral, Actiq, Fentora & Onsolys) 6-8 units/30 days then prior authorization up to 120 units/30 dayshydrocodone/APAP 240 tabs/30 days hydrocodone/ibuprofen 150 tablets/30 dayshydromorphone IR ( Dilaudid) 180 tablets/30 dayslevorphanol (Levo Dromoran) 180 tablets/30 daysmeperidine (Demerol) 180 tablets/30 daysmethadone (Dolophine, Methadose) 180 tablets/30 daysmorphine CR (MS Contin) 90 tablets/30 daysmorphine ER 120 capsules/30 daysmorphine IR 180 tablets/30 daysmorphine SR (Kadian) 120 tablets/30 days oxycodone IR 120 tablets/30 daysoxycodone ER (Oxycontin) 120 tablets/30 daysoxycodone/APAP or oxycodone/ASA (Percocet, Percodan) 240 tabs/30 daysoxycodone/ibuprofen 150 tablets/30 daysoxymorphone (Opana ER) 120 tabs/30 daysoxymorphone (Opana IR) 120 tablets/30 daystapentadol (Nucynta/Nucynta ER) 180 tablets/30 days
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2016 Formulary Exclusion List
Excluded AlternativesAbsorica isotretinoinAciphex omeprazole 20 mgActiclate doxcyclineAkynzeo granisetron, ondansetron, Anzemet
Analpram E hydrocortisone/pramoxineAplenzin bupropion ext-relAptensio XR methylphenidate ERArnuity Ellipta Asmanex HFA, Flovent Diskus, Flovent HFA,
Qvar
Axiron Androgel PABelsomra eszopiclone, zaleplon, zolpidem, zolpidem
ext-relBethkis tobramycin ampules QL, Tobi QL, Tobi
Podhaler QLBrintellix generic SSRIBrisdelle paroxetine hclBulk Powders & Select Bulk ChemicalsBunavail buprenorphine/naloxone, Suboxone SL filmCambia diclofenac tabletscapsaicin/menthol patches OTC capsaicin
Cetraxal ciprofloxacin otic solnClindacin Pac clindamycin topicalComfort Pac-Cyclobenzaprine
cyclobenzaprine
Comfort Pac-Ibuprofen ibuprofenComfort Pac-Naproxen naproxenComfort Pac-Tizanidine tizanidineConzip tramadol or tramadol ext-relCosentyx Enbrel PA SPRx, Humira PA SPRxDeprizine ranitidineDexilant omeprazole, pantoprazole, NexiumDexvenlafaxine ER generic SSRI, generic SNRIDiclegis OTC doxylamine, OTC pyridoxineDicopanol OTC diphenhydramineDoryx doxycyline immediate-releaseDisalcid salsalate
Duexis ibuprofen and OTC famotidineEcoza econazole nitrateEdular zolpidem tartrate oralEgriftaEligen B12 cyanocobalaminEloctate Advate SPRxEmbeda morphine sulfate ext-rel QL, Nucynta ER QL,
Opana ER QL, Oxycontin QL
esomeprazole strontium omeprazole, pantoprazole, NexiumEvzio naloxoneExalgo hydromorphoneFanatrex gabapentinFentanyl 37.5mcg,
62.5mcg, 87.5mcgfentanyl patch 12mcg, 25mcg, 50mcg,
75mcg, 100mcg
Excluded AlternativesFetzima generic SSRI, generic SNRIFortesta Androgel PA
Forfivo XL bupropion ext-relGlumetza Metformin ERGralise gabapentinGrowth Hormones
(other than Norditropin PA, including but not limited to: Genotropin, Humatrope, Nutropin, and Omnitrope)
Norditropin PA
Hemangeol propranolol oral solutionHetlioz OTC melatoninhydromorphone er hydromorphoneHysingla ER hydrocodone/apapIncruse Ellipta Spiriva, Tudorza Pressair
Intermezzo zaleplon, zolpidem, zolpidem ext-relIxinity BeneFIX SPRxJardiance Farxiga, InvokanaJublia ciclopirox topical solution
Karbinal ER carbinoxamine maleateKazano Janumet, JentaduetoKerydin ciclopirox topical solution
Khedezla generic SSRI, generic SNRI Kitabis tobramycin ampules QL, Tobi QL, Tobi
Podhaler QLKombiglyze XR JanumetLamisil Oral Granules terbinafine tabletsLatisseLazanda fentanyl lozenges QLLovaza OTC fish oil, fenofibrate, gemfibrozilLuzu econazole nitrateMedical foodsMetozolv ODT metoclopramideMigralam isometheptene/caffeine/APAP
Mimyx OTC moisturizers and emollientsMinocin Combo Pack minocyclineminocycline ext-rel minocycline immediate-releaseMirvaso Finacea, topical metronidazoleProvigil Nuvigil PA, modafinil PA
Momexin mometasone, OTC Lac-HydrinMonodox doxycycline monohydrate Morgidox doxycyclineMovantik AmitizaMoxatag amoxicillinNalfon 400 mg fenoprofen 200 mg, 300 mgNasacort AQ budesonide, flunisolide, fluticasone proprionate,
Veramyst, DymistaNascobal cyanocobalaminNatesto Androgel PANesina Januvia or Tradjenta
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20
2016 Formulary Exclusion List
Excluded AlternativesNovoeight Advate SPRxNymalize nimodipineObivan CF acetaminophen/butalbitalOleptro trazodoneOlysio Harvoni, Sovaldiomega-3 acid ethyl esters OTC fish oil, fenofibrate, gemfibrozilomeprazole/sodium
bicarbonateomeprazole 20 mg
Onexton Acanya, benzoyl peroxide/clindamycin
Onglyza Januvia, TradjentaOracea doxycyclineOseni Januvia or Tradjenta, plus pioglitazoneOtrexup methotrexateOxycodone ER OxyContin QL
Pediaderm HC OTC hydrocortisone creamPennsaid oral diclofenacPrescription drugs with
over-the-counter (OTC) equivalents
Prodrin isometheptene/apap/caffeineProvigil Nuvigil PA, modafinil PAPrumyx OTC moisturizers and emollientsQnasl budesonide, flunisolide, fluticasone
proprionate, Veramyst, Dymistarabeprazole omeprazole, pantoprazole, NexiumRayos prednisoneRectiv nitroglycerin ointmentRegimex diethylpropion, phendimetrazine,
phentermineRytary carbidopa/levodopa ext-relSancuso oral granisetronSilenor doxepinSingle-source brand
genericsSitavig acyclovir, famciclovir, valacyclovirSivextro linezolidSklice LindaneSodium Sulfacetamide
Kitsulfacetamide sodium/sulfur
Solodyn minocyclineSoolantra Finacea, topical metronidazole
Subsys fentanyl lozenges QLSumadan sulfacetamide/sulfurSumaxin CP sulfacetamide/sulfurSynapryn tramadol & OTC glucosamineTabradol cyclobenzaprine & OTC MSMTanzeum Bydureon, Byetta, VictozaTerbinex Kit terbinafineTirosint levothyroxineTivorbex indomethacin
Excluded AlternativesToviaz oxybutynin, oxybutynin ER, Enablex,
VesicareTreximet sumatriptan & naproxen, almotriptan,
naratriptan, rizatriptan, zolmitriptan, & ibuprofen
Trezix acetaminophen/caffeine/dihydrocodeinetriamcinolone acetonide budesonide, flunisolide, fluticasone
proprionate, Veramyst, DymistaTrulicity Bydureon, Byetta, and VictozaUceris CortifoamUTA Urogesic-Blue, Uro-BlueVascepa OTC fish oil, fenofibrate, gemfibrozilVecamyl generic ACE inhibitor, ARB, beta-blocker,
or calcium channel blockerVeltin clindamycin topical & tretinoinVersacloz clozapineViekira Harvoni, SovaldiViibryd generic SSRIVimovo naproxen & OTC omeprazoleVituz hydrocodone/chlorpheniramine
suspensionVogelxo Androgel PAXartemis XR oxycodone/acetaminophenXerese Zovirax & OTC hydrocortisone creamZegerid omeprazole 20 mg
Zetonna budesonide, flunisolide, fluticasone proprionate, Veramyst, Dymista
Ziana clindamycin topical & tretinoin
Zipsor diclofenac potassium
Zohydro ER hydrocodone/apap
Zolpimist zolpidem
Zorvolex diclofenac sodium
Zuplenz ondansetron
Zyflo, Zyflo CR montelukast, zafirlukast
Zypram hydrocortisone acetate/pramoxine
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Affordable Care Act Requirements
The Affordable Care Act (ACA) requires certain categories of drugs and immunizations are included in preventive care services coverage based on recommendations from the U.S. Preventive Services Task Force (USPSTF). These recommendations are important in preventing diseases as well as providing additional women’s services such as contraception.
Drug or Drug Category Description Coverage Criteria ReasonAspirin Generic OTC 81mg and 325mg Males ages 45-79 years and
Females ages 55 to 79 yearsPrevent cardiovascular disease
Bowel preparation agents Generic OTC and prescription products plus brand products that do not have a generic equivalent
Males and Females ages 50 to 75 Limit 2 scripts filled per 365 days
Preparation for colonoscopy screening
Breast Cancer Generic tamoxifen & raloxifene Asymptomatic women age 35 years and older who are at in-creased risk for breast cancer
Prevention of breast cancer in women at high-risk
Fluoride Generic OTC and prescription products
Children older than 6 months through 5 years old
Prevent dental cavities if water source is deficient in fluoride
Folic Acid Generic OTC and prescription products 0.4mg - 0.8mg
Females through age 50 years Prevent birth defects
Iron Supplements Generic OTC and prescription products
Children ages 6-12 months Prevent anemia due to iron deficiency
Smoking Cessation Generic OTC and prescription products plus brand Chantix
Males and Females age 18 years and older who use tobacco products
Increase in health benefits from successfully quitting smoking
Vaccines All prescription vaccines Ages per Advisory Committee on Immunization Practices (ACIP) recommendations
Prevention of infectious diseases
Vitamin D Generic OTC and prescription products (doses less than 1000 IU per dosage form)
Males and Females ages 65 and older who are at increased risk for falls
Prevent falls in community-dwell-ing adults who are at increased risk of falls
Women's Contraceptives Generic prescription oral contra-ceptives plus brand oral contra-ceptives that do not have a generic equivalent
Females only – See Contraceptive Drug List
Prevent pregnancy
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22
Prescription Contraceptive Drug List
According to the Women’s Preventive Services provision of the Affordable Care Act, BlueCross BlueShield of Tennessee offers access to prescription contraceptive drugs in this drug list to eligible members at no cost when filled by in-network pharmacies. This provision is effective during your employer group’s benefit enrollment period.
The drugs listed below are prescription generic oral and injectable contraceptives, vaginal ring and hormonal patch, and are covered at no cost to you.
MonophasicAltavera Enskyce Low-Ogestrel Previfem
Alyacen Estarylla Lutera Reclipsen
Amethyst Falmina Marlissa Safryal
Apri Generess Fe Microgestin Sprintec
Aubra Gianvi Microgestin FE Sronyx
Aviane Gildagia Minastrin 24 Fe Syeda
Balziva Gildess Moni-Linyah Tarina FE
Beyaz Gildess FE Mononessa Vestura
Briellyn Gildess 24 FE Necon Vyfemia
Chateal Introvale Nikki Wera
Cryselle Junel norgestrel-ethinyl estra Wymzya FE
Cyclafem Junel FE norgestimate-ethinyl estradiol Zarah
Cyred Kelnor 1-35 Nortrel Zenchent
Dasetta Kurvelo Ocella Zenchent FE
Desogestrel-ethynyl estradiol Larin FE Ogestrel Zeosa
Delyla Larin 24 FE Orsythia Zovia 1-35E
drospirenone-ethinyl estradiol Layolis FE Philith Zovia 1-50E
Elinest Lessina Pirmella I-35
Emoquette Levora-28 Portia
Lomedia 24 FE
Loryna
BiphasicAshlyna
Azurette Kariva Lo Loestrin Fe Pimtrea
Daysee Kimidess Lo Minastrin Fe Viorele
TriphasicAlyacen Leena Nortrel Tri-Linyah
Aranelle Levonest Ortho Tri-Cyclen Lo Tri-Previfem
Caziant levonorgestrel-eth estradiol Pirmella 7/7/7 Tri-Sprintec
Cyclafem Myzilra Tilia FE Trinessa
Dasetta Necon Tri-Estarylla Trivora-28
Enpresse norgestimate-ethinyl estradiol Tri-Legest FE Velivet
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23
Prescription Contraceptive Drug List
Extended-Cycle Amethia Camrese Jolessa Quartette
Amethia Lo Camrese Lo levonorgestrel-ethinyl estradiol Quasense
Progestin-Only Camila Errin Lyza Norlyroc
Deblitane Heather Nora-BE norethindrone acetate 0.35
depot medroxyprogesterone acetate (eq. to Depo Provera 150mg)
Jencycla Norlyrae Sharobel
Jolivette
Miscellaneous/Alternate Therapeutic Options Ella QL Natazia Nuvaring
My Way QL Next Choice OneDose QL Xulane
IUD’sIntrauterine Devices are available through the prescribing provider as a Medical Benefit at zero member liability; in accordance with the Women’s Preventive Services provision. These are not covered via the Pharmacy Benefit.
This list is subject to change throughout the year. Please call Member Service at 1-866-843-3509 or visit our website at bcbst.com/members/nissan for the most up-to-date information.
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24
Notes
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25
Notes
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15PHM3302 (11/15) Nissan_Guide_to_
Prescription_Drug_Benefits
For TDD/TTY help call 1-800-848-0299.Spanish: Para obtener ayuda en español, llame al 1-800-565-9140 Tagalog: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-565-9140 Chinese: 如果需要中文的帮助,请拨打这个号码 1-800-565-9140 Navajo: Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-565-9140
BlueCross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association
1 Cameron Hill Circle | Chattanooga, TN 37402 | bcbst.com